An Algorithmic Framework for Reducing Near-Fatal Aspiration Events: A Single-Institution Experience

Area of Science:

• Patient Safety
• Pulmonary Medicine
• Critical Care

Background:

• Aspiration-related cardiopulmonary arrests (CPAs) are a severe complication with a survival rate below 10%.
• These events are often preventable, highlighting a critical gap in patient care protocols.

Purpose of the Study:

• To reduce the incidence of aspiration-related CPAs in hospitalized patients.
• To identify root causes of aspiration events and implement effective interventions.

Main Methods:

• A multidisciplinary team reviewed aspiration cases (2020-2024) to identify contributing factors.
• Interventions included enhanced education for staff, improved swallow screening, revised nasogastric (NG) tube management, and high-risk patient signage.

Main Results:

• Aspiration-related CPAs decreased by 52% (from 27 events in 2023 to 13 in 2024) after intervention implementation.
• Statistical process control analysis confirmed a significant reduction in events.

Conclusions:

• A multipronged, multidisciplinary strategy effectively lowers the incidence of fatal aspiration events.
• Comprehensive education, improved screening, and standardized precautions are key to reducing aspiration-related CPAs.